CMS Manual System Pub 100-04 Medicare Claims Processing

CMS Manual System
Department of Health &
Human Services (DHHS)
Pub 100-04 Medicare Claims Processing
Centers for Medicare &
Medicaid Services (CMS)
Transmittal 2957
Date: May 16, 2014
Change Request 8764
SUBJECT: July 2014 Integrated Outpatient Code Editor (I/OCE) Specifications Version 15.2
I. SUMMARY OF CHANGES: This notification provides the Integrated OCE instructions and
specifications for the Integrated OCE that will be utilized under the OPPS and Non-OPPS for hospital
outpatient departments, community mental health centers, all non-OPPS providers, and for limited services
when provided in a home health agency not under the Home Health Prospective Payment System or to a
hospice patient for the treatment of a non-terminal illness. The attached Recurring Update Notification
applies to 100-04, Chapter 4, section 40.1.
EFFECTIVE DATE: July 1, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: July 7, 2014
Disclaimer for manual changes only: The revision date and transmittal number apply only to red
italicized material. Any other material was previously published and remains unchanged. However, if this
revision contains a table of contents, you will receive the new/revised information only, and not the entire
table of contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.
R/N/D
CHAPTER / SECTION / SUBSECTION / TITLE
N/A
III. FUNDING:
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is
not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
IV. ATTACHMENTS:
Recurring Update Notification
Attachment - Recurring Update Notification
Pub. 100-04
Transmittal: 2957
Date: May 16, 2014
Change Request: 8764
SUBJECT: July 2014 Integrated Outpatient Code Editor (I/OCE) Specifications Version 15.2
EFFECTIVE DATE: July 1, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: July 7, 2014
I.
GENERAL INFORMATION
A. Background: This instruction informs the A/B MACs, the HHH MACs and the Fiscal Intermediary
Shared System (FISS) that the I/OCE is being updated for July 1, 2014. The I/OCE routes all institutional
outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE, which
eliminates the need to update, install, and maintain two separate OCE software packages on a quarterly
basis. The attached Recurring Update Notification applies to 100-04, Chapter 4, section 40.1.
B. Policy: This notification provides the Integrated OCE instructions and specifications for the Integrated
OCE that will be utilized under the OPPS and Non-OPPS for hospital outpatient departments, community
mental health centers, all non-OPPS providers, and for limited services when provided in a home health
agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a
non-terminal illness. The I/OCE specifications will be posted to the CMS Website and can be found at
http://www.cms.gov/OutpatientCodeEdit/.
II.
BUSINESS REQUIREMENTS TABLE
"Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.
Number
Requirement
8764.1
The Shared System Maintainer shall install the
Integrated OCE (I/OCE) into their systems.
8764.2
Medicare contractors shall identify the I/OCE
specifications on the CMS Website at
http://www.cms.gov/OutpatientCodeEdit/
Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
H M I C M W
H A S S S F
C S
X
X
X
X
Other
III.
PROVIDER EDUCATION TABLE
Number
Requirement
Responsibility
A/B
MAC
D
M
E
M
A
C
A B H
H
H
8764.3
IV.
MLN Article : A provider education article related to this instruction will be
available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/ shortly after the CR is released. You will
receive notification of the article release via the established "MLN Matters"
listserv. Contractors shall post this article, or a direct link to this article, on their
Web sites and include information about it in a listserv message within one week
of the availability of the provider education article. In addition, the provider
education article shall be included in the contractor’s next regularly scheduled
bulletin. Contractors are free to supplement MLN Matters articles with localized
information that would benefit their provider community in billing and
administering the Medicare program correctly.
X
X
SUPPORTING INFORMATION
Section A: Recommendations and supporting information associated with listed requirements: N/A
"Should" denotes a recommendation.
X-Ref
Requirement
Number
Recommendations or other supporting information:
Section B: All other recommendations and supporting information: CR 5344, Transmittal 1107:
Notification of an Integrated Outpatient Code Editor (OCE) for the July 2007 Release
V. CONTACTS
Pre-Implementation Contact(s): Yvonne Young, Yvonne.Young@cms.hhs.gov , Anita Antkowiak,
Anita.Antkowiak2@cms.hhs.gov , Marina Kushnirova, Marina.Kushnirova@cms.hhs.gov
Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR).
VI. FUNDING
Section A: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is
not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
C
E
D
I
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
ATTACHMENTS: 2
FINAL
Summary of Data Changes
Integrated OCE v 15.2
Effective July 1, 2014
Table of Contents
CPT codes, descriptions, and material only are Copyright 2013 American Medical Association. All Rights Reserved. No fee
schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
DEFINITIONS ............................................................................................................................................ 7
APC CHANGES ......................................................................................................................................... 8
Added APCs............................................................................................................................................ 8
APC Description Changes ...................................................................................................................... 8
APC Status Indicator Changes ................................................................................................................ 8
HCPCS/CPT PROCEDURE CODE CHANGES ....................................................................................... 8
Added HCPCS/CPT Procedure Codes .................................................................................................... 8
Deleted HCPCS/CPT Procedure Codes .................................................................................................. 9
HCPCS Description Changes.................................................................................................................. 9
HCPCS Changes- APC, Status Indicator and/or Edit Assignments........................................................ 9
MODIFIERS ............................................................................................................................................... 9
Added Modifiers ................................................................................................................................... 10
DEFINITIONS
•
A blank in a field indicates ‘no change’
•
The “old” column describes the attribute prior to the change being made in the current update, which is indicated in the
“new” column. If the effective date of the change is the same as the effective date of the new update, ‘old’ describes the
attribute up to the last day of the previous quarter. If the effective date is retroactive, then ‘old’ describes the attribute for
the same date in the previous release of the software.
•
“Unassigned”, “Pre-defined” or “Placeholder” in APC or HCPCS descriptions indicates that the APC or HCPCS code is
inactive. When the APC or HCPCS code is activated, it becomes valid for use in the OCE, and a new description
appears in the “new description” column, with the appropriate effective date.
•
Activation Date (ActivDate) indicates the mid-quarter date of FDA approval for a drug, or the mid-quarter date of a new
or changed code resulting from a National Coverage Determination (NCD). The Activation Date is the date the code
becomes valid for use in the OCE. If the Activation Date is blank, then the effective date takes precedence.
•
Termination Date (TermDate) indicates the mid-quarter date when a code or change becomes inactive. A code is not
valid for use in the OCE after its termination date.
•
For codes with SI of “Q1, Q2, and Q3”, the APC assignment is the standard APC to which the code would be assigned if
it is paid separately.
APC CHANGES
Added APCs
The following APC(s) were added to the IOCE, effective 07-01-14
APC
01480
01481
02644
APCDesc
Injection, elosulfase alfa
Factor XIII A-subunit recomb
Brachytx cesium-131 chloride
StatusIndicator
G
G
U
APC Description Changes
The following APC(s) had description changes, effective 07-01-14
APC
09441
Old Description
Inj, ferric carboxymaltose
New Description
Inj Ferric Carboxymaltos
1mg
APC Status Indicator Changes
The following APC(s) had Status Indicator changes, effective 07-01-14
APC
01477
Old SI
K
New SI
G
HCPCS/CPT PROCEDURE CODE CHANGES
Added HCPCS/CPT Procedure Codes
The following new HCPCS/CPT code(s) were added to the IOCE, effective 07-01-14
HCPCS
0347T
0348T
0349T
0350T
0351T
0352T
0353T
0354T
0355T
0356T
0358T
0359T
0360T
0361T
0362T
0363T
0364T
0365T
0366T
CodeDesc
Ins bone device for rsa
RSA spine exam
RSA upper extr exam
RSA lower extr exam
Intraop oct brst/node spec
Oct brst/node i&r per spec
Intraop oct breast cavity
Oct breast surg cavity i&r
GI tract capsule endoscopy
Insrt drug device for iop
BIA whole body
Behavioral id assessment
Observ behav assessment
Observ behav assess addl
Expose behav assessment
Expose behav assess addl
Behavior treatment
Behavior treatment addl
Group behavior treatment
SI
Q2
X
X
X
N
B
N
B
T
S
Q1
V
V
N
V
N
S
N
S
APC
00420
00261
00261
00261
00000
00000
00000
00000
00142
00698
00340
00632
00632
00000
00632
00000
00322
00000
00325
Edit
62
62
ActivDate
TermDate
HCPCS
0367T
0368T
0369T
0370T
0371T
0372T
0373T
0374T
C2644
C9022
C9134
Q9970
Q9974
S0144
S1034
S1035
S1036
S1037
CodeDesc
Group behav treatment addl
Behavior treatment modified
Behav treatment modify addl
Fam behav treatment guidance
Mult fam behav treat guide
Social skills training group
Exposure behavior treatment
Expose behav treatment addl
Brachytx cesium-131 chloride
Injection, elosulfase alfa
Factor XIII A-subunit recomb
Inj Ferric Carboxymaltos 1mg
Morphine epidural/intratheca
Propofol, 10mg
Art pancreas system
Art pancreas inv disp sensor
Art pancreas ext transmitter.
Art pancreas ext receiver
SI
N
S
N
S
S
S
S
N
U
G
G
G
N
E
E
E
E
E
APC
00000
00322
00000
00324
00324
00325
00323
00000
02644
01480
01481
09441
00000
00000
00000
00000
00000
00000
Edit
ActivDate
TermDate
55
55
55
9
9
9
9
9
Deleted HCPCS/CPT Procedure Codes
The following HCPCS/CPT code(s) were deleted from the IOCE, effective 07-01-14
HCPCS
C9441
CodeDesc
Inj, ferric carboxymaltose
HCPCS Description Changes
The following code descriptions were changed, effective 04-01-14
HCPCS
43752
G0416
Old Description
Nasal/orogastric /tube plmt
Biopsy 10-20
New Description
Nasal/orogastric w/tube plmt
Biopsy prostate 10-20
HCPCS Changes- APC, Status Indicator and/or Edit Assignments
The following code(s) had an APC and/or SI and/or edit change, effective 04-01-14 **A blank in the field indicates
no change.
HCPCS
Q2052
CodeDesc
Ivig demo, services/supplies
Old APC
New APC
Old SI
N
New SI
E
Old Edit
N/A
New Edit
9
The following code(s) had an APC and/or SI and/or edit change, effective 07-01-14 **A blank in the field indicates
no change.
HCPCS
J1446
J2271
J2275
CodeDesc
Inj, tbo-filgrastim, 5 mcg
Morphine so4 injection 100mg
Morphine sulfate injection
MODIFIERS
Old APC
New APC
Old SI
K
N
N
New SI
G
E
E
Old Edit
New Edit
N/A
N/A
9
28
Added Modifiers
The following modifier(s) were added to the list of valid modifiers, effective 01-01-14
modif
L1
ACTIVATIONDATE
0
The following modifier(s) were added to the list of valid modifiers, effective 07-01-14
modif
SZ
ACTIVATIONDATE
0
Appendix M
Summary of Modifications
The modifications of the IOCE for the July 2014 release (V15.2) are summarized in the table below.
Readers should also read through the entire document and note the highlighted sections, which also indicate changes
from the prior release of the software.
Some IOCE modifications in the update may also be retroactively added to prior releases. If so, the retroactive date
will appear in the 'Effective Date' column.
#
Type
Logic
Effective
Date
7/1/2014
Edits
Affected
24
1.
2.
Logic
10/1/2014
86
3.
Logic
1/1/2014
-
4.
5.
6.
7.
8.
Content
Content
Content
Content
Doc
7/1/2014
7/1/2014
1/1/2014
7/1/2014
1/1/2014
20, 40
22
22
-
9.
Doc
7/1/2014
-
10.
Other
7/1/2014
-
11.
Other
7/1/2014
-
Modification
Modify the software to maintain 28 prior quarters (7 years) of programs in each release. Remove
older versions with each release.
(The earliest version date included in this July 2014 release is 10/1/2007).
Modify the effective begin date for edit 86 from 10/1/2013 to 10/1/2014, to be applied for claims
with hospice bill types, 81X and 82X.
Modify the logic for packaged laboratory services. If packaged laboratory services are submitted
on a 13X bill type with modifier L1, change the SI from N to A.
Make HCPCS/APC/SI changes as specified by CMS (data change files).
Implement version 20.2 of the NCCI (as modified for applicable institutional providers).
Add new modifier L1 (Separately payable lab test) to the valid modifier list.
Add new modifier SZ (Habilitative services) to the valid modifier list.
Updated documentation in Appendix F(a) and Appendix L to include bill type 13x for laboratory
services reported with modifier L1.
Documentation change only: modified Appendix N, List B (PHP Services) to note the add-on
codes in a separate list as part of “PHP List C”, referred to in Appendix C-a (Partial
Hospitalization Logic effective v10.0).
Create 508-compliant versions of the specifications & Summary of Data Changes documents for
publication on the CMS web site.
Deliver quarterly software update & all related documentation and files to users via electronic
means.